The Downsides of Excluding Millions of Immigrants from Health Reform

The Affordable Care Act of 2010 promises to extend health insurance coverage to tens of millions of uninsured people across the United States – but not to everyone. Non-citizens are among those most likely to lack health insurance coverage, yet large segments of the immigrant population have been excluded from the benefits of health reform – and may face greater barriers in the future than in the past.

Immigrants Not Qualified for New Health Coverage

When it comes to defining immigrants who are eligible – or not – for benefits, the Affordable Care Act legislation makes detailed distinctions among various types of immigrants:

Regardless of how long they have been in the country, “lawfully present immigrants” with modest incomes are eligible to get tax credits to help them purchase private health insurance coverage on marketplace exchanges.

However, to be eligible for Medicaid coverage in states that choose to expand this program, lawfully present immigrant adults must have been in the United States for at least five years. States can choose to extend Medicaid coverage to immigrant children here less than five years.

Student visa holders and temporary workers are deemed “non-qualified” immigrants, who cannot get benefits such as subsidies nor participate in the exchanges.

An estimated twelve million undocumented immigrants are defined as “not lawfully present” and therefore not eligible for premium tax subsidies or Medicaid coverage. They cannot purchase health plans on the marketplaces even with their own money, and they are exempt from the mandate requiring health insurance coverage or the payment of a penalty.

Also lumped with all other undocumented immigrants are up to two million immigrant young people originally brought to the United States as undocumented children. They are deemed ineligible for health reform benefits, even though they can apply for work permits and protection from deportation under the Deferred Action for Childhood Arrivals program established by the Obama Administration in 2012. This exclusion is unusual, because other categories of immigrants granted similar temporary legal status are eligible for social benefits.

Undocumented immigrants can still get care at emergency rooms, through some state and local programs, and at federally supported community health centers serving poor populations in urban and rural areas. But they usually cannot get advanced or specialist care, and may not be able to afford even basic medical care. Furthermore, as the Affordable Care Act is fully implemented in coming years, it is possible that public support will decline for programs that treat uninsured persons. If so, undocumented immigrants may become more marginalized in the U.S. health system.

Families Where Only Some Members are Eligible

In the real world, immigrants do not sort neatly into legal versus undocumented families. Many families are “mixed status,” and there are special concerns about how health reform impacts an estimated 2.3 million families that include combinations of citizens, permanent legal residents, undocumented immigrants, and individuals in legal limbo or in temporary statuses such as the youth in the Deferred Action for Childhood Arrivals program.

The majority of children in mixed-status families are U.S. citizens by birth. Indeed, such citizen children make up three-quarters of all children being raised by undocumented adults in this country. Health care is essential for children’s wellbeing, so health reform advocates are naturally very concerned about what will happen for the 4.5 million citizen children plus one million undocumented children being raised in mixed-status immigrant households. Will all those eligible for health coverage under Affordable Care get it? What about the rest?

Research shows that U.S. citizen children of immigrants are directly impacted by the “illegality” of parents. Despite the eligibility of such children for Medicaid and State Children’s Health Insurance Programs, they tend to enroll at a much lower rate than children of citizen parents. There are straightforward reasons why citizen children often remain uncovered. Fear of deportation leads some mixed-status families to limit or delay getting services for children; and fearful adults may even withdraw from programs altogether. Moreover, some undocumented parents lack proper identification documents or worry that enrolling children in social programs will hurt future chances to get regular legal status through family sponsorships. Immigrant applicants for permanent residency in the United States must prove they will not be primarily dependent on the government, and this requirement has – mistakenly – led some families to think that they cannot get health services for children.

Even if fears are overcome, mixed-status families experience risks of confusion when eligible members try to take advantage of health programs under the new Affordable Care Act. Some members but not others may be subject to the legal mandate to get coverage; some members may “count” in calculations for subsidies, while others do not. The bottom line is that defining some family members as “illegal” or “ineligible” colors the experience for all.

The Road Ahead

Higher barriers to affordable health coverage for certain categories of residents hold worrisome implications for the future of American health care. In coming years, undocumented immigrants may account for up to one quarter of all uninsured people. Political problems will follow, and public health is certain to suffer if America countenances a permanent medical underclass numbering well over twelve million. Long-term health problems and resulting social deficits will become apparent as children without adequate care grow into adulthood. Many of the children affected by the intensified exclusions embedded in the Affordable Care Act are, in fact, U.S. citizens – and others will surely become full citizens at some point down the road. Regardless of legal categorizations, immigrant families are raising many of America’s future workers and citizens. It makes little sense to exclude them from the affordable care options promised by the health care reform.